Hey Baby 4D Dartford

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

This is the first assessment for this service. This key question has been rated Good.

This meant the service was consistently managed and well-led. Leaders had clear vision and supported a positive culture, staff felt empowered to speak up and the service was equitable, women centred and managers strived to build partnerships with stakeholders.

However, we found a breach in regulation 17 Good Governance this was because there was limited oversight on stock checks, fire risk assessment and equipment maintenance checks.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Hey-Baby 4D Dartford scan was a location of Hey Baby West Kent both registered with the care quality commission for the regulated activity of diagnostic and screening services. The provider was part of a franchise, which means leaders paid to use a proven business model, its branding, and its systems.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

The providers successfully communicated the provider’s vision and values to the frontline staff in this service. The registered manager told us that the service aimed to provide parents with reassurance, as well as positive bonding experiences with their unborn baby throughout their pregnancy.

Staff could explain how they were working to deliver high quality care. All staff showed a true passion for their service. They knew what good care looked like and how important it was for families to receive care tailored to meet their needs. From the registered manager to the receptionist, we found staff were driven to offer a good service.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

The registered manager was also the director of the business. They had taken on the role in October 2024 and were still undergoing a review of the service when we inspected. They had the skills, knowledge and experience to perform their roles because they received obstetric and gynaecological medical training in their country of origin and were a registered sonographer within the United Kingdom.

The registered manager had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high-quality care.

The registered manager was visible in the service and approachable for women, families, and staff.

We did not look at Freedom to speak up during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The workforce was minimal and those working for the service came from different ethnic groups, which confirmed the provider was equally inclusive, and diversity was celebrated.

The registered managers made reasonable adjustments for staff members to help them carry out their role at their request.

The service captured ethnicity data as part of the initial risk assessment.

The service did not always have systems of accountability or good governance. However, they acted on information about risk, performance, and outcomes, and shared this securely with others when appropriate.

The service had clear lines of responsibility. However, we found gaps in the governance process, in terms of responsibility for maintaining the estates, equipment and stock checks.

Local clinical audits were completed on a regular basis. However, data was not collected by the registered manager to accurately monitor equipment and environment checks. The franchisor had not set any key quality indicators, so the registered manager did not benchmark the service against other locations in the Hey-baby group.

The registered manager oversaw the management of risk, issues and performance. We found that location risk assessments for fire evacuation, equipment testing and stock checking had not always been completed within expected time frames.

We found that the cleaning schedule did not include checks for expiry dates on single-use items, abdominal gel or transducer probe foam. Because of this, staff used out-of-date products, which may not work as well as products that are in date. We also found other out-of-date items, including vaginal probe decontamination foam and items in the first aid kit. The first aid kit did not include a checklist to make sure it was fully stocked and that items were in date.

We also found gaps in governance related to safety checks. The service had not completed portable appliance testing (PAT). The fire risk assessment was out of date, and some fire extinguishers were not in date. Although the provider responded quickly and acted, these gaps showed that the previous registered manager had not handed over responsibilities effectively.

During and after the inspection, we told the provider to take action to address gaps in environmental and equipment checks. The registered manager had been in post for six months. They told us they had not considered the fire risk because the service was based in a shopping precinct. They assumed the landlord covered fire risk assessments under the tenancy agreement. Once the registered manager confirmed that the service was responsible for fire safety and PAT testing, they arranged a fire risk assessment and PAT testing. Within one week of the inspection, they sent evidence to show both had been completed.

We found that the service used out-of-date decontamination gel for transvaginal probes. We asked the provider to stop providing transvaginal scans until they received new stock. The provider told us women were not put at risk because the sonographer used single-use sheaths to cover the probes. However, to ensure best practice, we asked the provider to identify all women who had received a transvaginal scan. The sonographer provided accurate records. While we were on site, the registered manager ordered new decontamination gel and a new first aid kit. They later sent evidence to CQC to confirm delivery and showed that they had updated stock checklists

After the inspection, the registered manager met with an NHS infection prevention and control (IPC) lead. This meeting provided assurance that IPC arrangements were safe, and no further concerns were raised with us.

Since joining the service, the registered manager had started to review policies and procedures. This work was ongoing. We found that policies did not clearly show their implementation dates although, the registered manager had dated and signed them when they completed reviews. The governance policy stated that the service would review policies and procedures every year.

The service had a risk matrix that listed known risks and actions to reduce them. These included infection control, slips and trips, electrical safety, fire, and ultrasound risks. The registered manager acted on our findings and took steps to improve how the service reviewed risks and completed checks each year.

The registered manager acted in a professional and proactive way. They addressed the concerns we raised quickly and reduced the risks we identified.

Staff received information governance training to help them keep records safe. Information was easy to access, accurate, and shared in a timely way. It also highlighted areas where the service needed to improve.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager engaged with external stakeholders – such as the NHS and local Integrated Care Board to ensure the service was aligned to best practice and service user needs. They advised that they were taking steps to engage with the local NHS trust to act as support to alleviate long patient waiting times. Their plan was to gain an NHS service level agreement.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contribute to safe, effective practice and research.

This was a franchise therefore the provider followed the franchise model of operation and improvement.

Staff were committed to improving services. There were systems and processes in place for learning. Staff were encouraged to attend further training for their development for example, the reception staff had completed her non-invasive prenatal testing (NIPT) training.